Codes Drug Name J3262 Actemra (tocilizumab) C9053, J0791 Adakveo (crizanlizumab-tmca) J9042 Adcetris (brentuximab) J9057 Aliqopa (copanlisib) J7207 Adynovate (factor viii peg rco) C9072 Asceniv (immune globulin) J9118 Asparlas (calaspargase pegol-mknl) C9407, C9408, Azedra (iobenguane I 131) A4641, A9590 C9491, J9023 Bavencio (avelumab) J9032 Beleodaq (belinostat) C9042 Belrapzo (bendamustine) J9034 Bendeka (bendamustine) C9028, J9229 Besponsa (inotuzumab ozogamicin) C9069 Blenrep (belantamab mafodontin-blm) J9039 Blincyto (bliantumab) J0585 Botox (onabotulinumtoxin A) C9014, J0567 Brineura (cerliponase alfa) C9047 Cablivi (caplacizumab-yhdp) J1566 Carimune NF(immune globulin) J0717 Cimzia (certolizumab) C9481, J2786 Cinqair (reslizumab) J0584 Crysvita (burosumab-twza) J9308 Cyramza (ramucirumab) J9144, J9145 Darzalex (daratumumab) J0586 Dysport (abobotulinimumtoxin A) C9049, J9269 Elzonris (tagraxofusp) C9477, J9176 Empliciti (elotuzumab) J9358 Enhertu (fam-trastuzumab deruxtecan-nxki) J3380 Entyvio (vedolizumab) J9019 Erwinaze (asparaginase Erwinia chrysanthemi) J7204 Esperoct (factor viii glyco rco) J3111 Evenity (romosozumab-aqqg) C9484, J1428 Exondys 51 (eteplirsen) C9466, J0517 Fasenra (benralizumab) J1572 Flebogamma (immune globulin) J1460, J1560 GamaSTAN S/D (gamma globulin) C9050, J9210 Gamifant (emapalumab-lzsg) J1569 Gammagard (immune globulin) J1557 Gammaplex (immune globulin) J1561 Gamunex/Gamunex-C (immune globulin) J9301 Gazyva (obinutuzumab) C9056, J0223 Givlaari (givosiran) J7170 Hemlibra (emicizumab-kxwh) J1670 HyperTET S/D (tetanus immune globulin) (Medicare members only) J7202 Idelvion (factor ix) J0638 Ilaris (cankinumab) J3245 Ilumya (tildrakizumab-asmn) C9492, J9173 Imfinzi (durvalumab) J9325 Imlygic (talimogene laherparepvec) C9065 Istodax (romidepsin) C9064, J9281 Jelmyto (mitomycin pyelocalyceal) C9141 Jivi (anithemophilic factor) C9478, J2840 Kanuma (sebelipase alfa)
Capital Health Plan MMS Dept. Updated 03/30/21 J9271 Keytruda (pembrolizumab) J2507 Krystexxa (pegloticase) Q2042 Kymriah (tisagenlecleucel) C9485, J9285 Lartruvo (olaratumab) J0202 Lemtrada (alemtuzumab) C9044, J9119 Libtayo (cemiplimab-rwlc) C9045, J9313 Lumoxiti (moxetumomab pasudotox-tdfk) C9031, A9513 Lutathera (lutetium Lu 177 dotatate) C9032, J3398 Luxturna (voretigene neparvovec-rzyl) J3397 Mepsevii (vestronidase alfa-vjbk) C9070 Monjuvi (tafasitamab-cxix,) J9203 Mylotarg (gemtuzumab ozogamicin) J0587 Myobloc (rimabotulinumtoxin B) J2182 Nucala (mepolizumab) J7209 Nuwiq (antihemophilic factor rco) C9494, J2350 Ocrevus (ocrelizumab) J1568 Octagam (immune globulin) J9205 Onivyde (irinotecan lisosome inj) C9036, J0222 Onpattro (patisiran sodium) J9299 Opdivo (nivolumab) J0129 Orencia (abatacept) J9177 Padcev (enfortumab vedotin-ejfv) J9316 Phesgo ( pertuzumab, trastuzumab, and hyaluronidase-zzx) J9309 Polivy (polatuzumab vedotin-piiq) J9295 Portrazza (necitumumab) C9038, J9204 Poteligeo (mogamulizumab-kpkc) J1459 Privigen (immune globulin) J0570 Probuphine (buprenorphine subdermal implant) Q2043 Provenge (sipuleucel-T) C9493, J1301 Radicava (edaravone) J7203 Rebinyn (factor ix rco gly) J0896 Reblozyl (luspatercept-aamt) J0596 Ruconest (C1 estrease inhibitor) J9227 Sarclisa (isatuximab-irfc) J7352 Scenesse (Afamelanotide implant) J7212 Sevenfact (antihemophilic factor, rco) J1602 Simponi Aria (golimumab) J1300 Soliris (eculizumab) C9489, J2326 Spinraza (nusinersen) Q9989, J3358 Stelara (ustekinumab) CPT 90378 Synagis (palivizumab) C9073 Tecartus (brexucabtagene autoleuce) C9483, J9022 Tecentriq (atezolizumab) C9061, J3241 Tepezza (teprotumumab-trbw) J9033 Treanda (bendamustine) C9066, J9137 Trodelvy (sacituzumab govitecan-hziy) J2323 Tysabri (natalizaumab) C9052, J1303 Ultomiris (ravulizumab) J1823 Uplinza (inebilizumab-cdon) J1325 Veletri (epoprostenol) C9071 Viltepso (viltolarsen) J7179 Vonvendi (von willwbrand factor rco) C9063, J3032 Vyepti (eptinezumab-jjmr) J1429 Vyondys 53 (golodirsen) C9024 Vyxeos (daunorubicin; cytarabine)
Capital Health Plan MMS Dept. Updated 03/30/21 J0588 Xeomin (incobotulinim toxin a) A9606 Xofigo (radium Ra 223 dichloride injection) J2357 Xolair (omalizumab) J9228 Yervoy (ipilimumab) Q2041 Yescarta (axicabtagene ciloleucel) C9480, J9352 Yondelis (trabectedin) J9223 Zepzelca (lurbinectedin) J3399 Zolgensma (onasemnogene abeparvovec-xio) J9999 Unclassified Antineoplastic drugs J3590, C9399 Unclassified biologics J7999 Unclassified compounded drug J3490 Unclassified drugs J3591 Unclassified drug or biologic used for ESRD on dialysis J1599 Unclassified Immune globulin
Capital Health Plan MMS Dept. Updated 03/30/21